UTILIZATION REVIEW NURSE

Sentara Health; Town of King (WI); On-site; USD 93,000 - 137,000; Full time

Benefits offered by this job

Medical, Dental, Vision plans

401k/403B with Employer Match

Paid Time Off and Holidays

Educational assistance or student loan

Student Debt Pay Down

Life Insurance

Disability plans

Tuition Assistance - Guild Education

Job summary

Sentara Health Plans Community Care is hiring a Utilization Review Nurse. This role manages utilization management services within licensure, including prior authorization, pre-certification, and care coordination to ensure appropriate treatment and policy compliance.

Requirements include RN license and BSN preferred, with 3+ years acute care experience and familiarity with Milliman and NCQA. Strong communication and analytical skills are essential.

Qualifications

• RN license required; BSN preferred.
• 3+ years acute care clinical experience; utilization review experience preferred.
• Milliman knowledge preferred; NCQA knowledge helpful.
• Proficient with Microsoft Office; strong communication and analytical skills.

Responsibilities

• Perform utilization management services including prior authorization, retrospective review, and care coordination.
• Coordinate pre-certification and ensure compliance with criteria, policies, and contracts.
• Provide written and/or verbal notification to members and providers; ensure consistency with criteria and regulatory standards.
• Apply accrediting and regulatory requirements and standards to practice.

Skills

3 years acute care clinical experience

Utilization Review experience

Strong oral, written and interpersonal

Problem-solving

Facilitation skills

Analytical skills

MS Office proficiency

Education

BSN (preferred)

Tools

Milliman

Microsoft Office (Excel, Word, Outlook)

Job description

City/State

Norfolk, VA

Work Shift

First (Days)

Overview

Sentara Health Plans Community Care is looking to hire a Utilization Review Nurse.

The Utilization Review Nurse is responsible for utilization management services within the scope of licensure. Conducts primary functions of prior authorization, retrospective review, medical director referrals and execution of member/provider approval and/or denial letter. Reviews provider requests for services requiring authorization. Conducts pre-certification, care coordination for appropriateness of treatment, set reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.

Responsible for written and/or verbal notification to members and providers. Ensures medical director written decision is consistent with criteria (CMS, state, medical policy, clinical criteria). Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.

Education

BSN (preferred)

Certification

Registered Nurse (required)

Experience

• 3 years of acute care clinical experience (required)
• Previous Utilization Review experience (preferred)
• Milliman experience (preferred)
• Knowledge of NCQA (preferred)
• Microsoft suite (Word, Excel, Outlook) (preferred)
• Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills

Keywords

Talroo- Health, Utilization Review Nurse, RN, Care Coordination, or Discharge Planning, Case Management, Milliman, NCQA

Compensation

We provide market-competitive compensation packages, inclusive of base pay, incentives, and benefits. The base pay range for full-time employment is $93,184.00 - $136,947.20 annually. Additional compensation may be available for this role, such as shift differentials, on-call pay, shift premiums, extra-shift incentives, or bonus opportunities. Compensation within the range may vary based on qualifications, experience, location, market conditions, and business needs. Note: If an annual salary is posted, it is based on a full-time colleague working 2,080 hours annually.

Sentara offers a comprehensive benefits package, including medical, dental, vision, life and disability insurance; 401(k)/403(b) with employer match; paid time off (vacation, sick time, and holidays); paid parental and military leave; educational assistance or student loan repayment; and voluntary benefits.

Benefits: Caring For Your Family and Your Career

• Medical, Dental, Vision plans
• Adoption, Fertility and Surrogacy Reimbursement up to $10,000
• Paid Time Off and Sick Leave
• Paid Parental & Family Caregiver Leave
• Emergency Backup Care
• Long-Term, Short-Term Disability, and Critical Illness plans
• Life Insurance
• 401k/403B with Employer Match
• Tuition Assistance - $5,250/year and discounted educational opportunities through Guild Education
• Student Debt Pay Down - $10,000
• Pet Insurance
• Legal Resources Plan
• Colleagues have the opportunity to earn an annual discretionary bonus if established system and employee eligibility criteria is met.

Sentara Health is an equal opportunity employer and prides itself on the diversity and inclusiveness of its close to an almost 30,000-member workforce. Diversity, inclusion, and belonging is a guiding principle of the organization to ensure its workforce reflects the communities it serves.

In support of our mission "to improve health every day," this is a tobacco-free environment.

Remote Work

Sentara Health employs associates in the following states:

Alabama, Delaware, Florida, Georgia, Idaho, Indiana, Kansas, Louisiana, Maine, Maryland, Minnesota, Nebraska, Nevada, New Hampshire, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Washington, West Virginia, Wisconsin, and Wyoming.